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Jugular Venous Pressure

Description

The jugular venous pressure (JVP) provides an indirect measure of central venous pressure. The internal jugular vein connects to the right atrium without any intervening valves - thus acting as a column for the blood in the right atrium. The JVP consists of certain waveforms and abnormalities of these can help diagnose certain conditions. Unfortunately, detection of these abnormalities and even the JVP itself, can be difficult and has also been superseded by other diagnostic methods.

How to examine the JVP1,2,3
  • Use the right internal jugular vein (IJV)
  • Patient should be at a 45° angle
  • Head turned slightly to the left
  • If possible have a tangential light source that shines obliquely from the left
  • Locate the surface markings of the IJV - runs from medial end of clavicle to the ear lobe under medial aspect of the sternocleidomastoid
  • Locate the JVP - look for the double waveform pulsation (palpating the contralateral carotid pulse will help)
  • Measure the level of the JVP by measuring the vertical distance between the sternal angle and the top of the JVP. Measure the height - usually less than 3cm.
Waveforms of the JVP

For a diagram see 4

Waves1,2,3

  • a - presystolic; produced by right atrial contraction
  • c - bulging of tricuspid valve into the right atrium during ventricular systole (isovolumic phase)
  • v - occurs in late systole; increased blood in right atrium from venous return

Descents

  • x - combination of atrial relaxation, downward movement of the tricuspid valve and ventricular systole
  • y - tricuspid valve opens and blood flows in to the right ventricle

The a and v wave can be identified by timing the double waveform with the opposite carotid pulse. The a wave will occur just before the pulse and the v wave occurs towards the end of the pulse. Distinguishing the c wave, x and y descents is an almost impossible task.

How to differentiate a jugular venous pulse from the carotid pulse

The JVP pulse is

  • Not palpable
  • Obliterated by pressure
  • Characterised by a double waveform
  • Varies with respiration - decreases with inspiration
  • Enhanced by the hepatojugular reflux (see below)

Hepatojugular reflux (abdominojugular reflux sign)5
  • This can help confirm that the pulsation is caused by the JVP
  • Firm pressure is applied to the right upper quadrant using the palm of the hand
  • A transient increase in the JVP will be seen in normal patients
  • There may be a delayed recovery back to baseline which is more marked in right ventricular failure
Causes of a raised JVP
Abnormalities of the JVP1,2,3

Abnormalities of the a wave

Prominent v waves

  • Tricuspid regurgitation - called cv or V waves and occur at the same time as systole (combination of v wave and loss of x descent); there may be ear lobe movement

Slow y descent

Steep y descent

  • Right ventricular failure
  • Constrictive pericarditis
  • Tricuspid regurgitation
  • (The last two conditions have a rapid rise and fall of the JVP called Friedreich's sign)

Prognostic use of the JVP

An elevated JVP in patients with heart failure is associated with an increased risk of hospital admission, death and subsequent hospitalization for heart failure.6 Therefore appreciation of this sign can be clinically helpful.

Document references
  1. Kumar P; Clarke M; Clinical Medicine, 6th Ed, (2005). WB Saunders: London.
  2. Harrison's Principles of Internal Medicine, 15th Ed. Eds: Braunwald, E et al. McGraw-Hill, USA 2001.
  3. Souhami, RL and Moxham, J (Eds). Textbook of medicine, 4 th edition, (2002), Churchill Livingstone: China.
  4. JVP Waveforms - provides a good image of jugular venous pulsations; University of California - Hospitalist Handbook; 2002.
  5. Wiese J; The abdominojugular reflux sign. Am J Med. 2000 Jul;109(1):59-61. [abstract]
  6. Drazner MH, Rame JE, Stevenson LW, et al; Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med. 2001 Aug 23;345(8):574-81. [abstract]
Internet and further reading Acknowledgements EMIS is grateful to Dr Gurvinder Rull for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 2350
Document Version: 21
DocRef: bgp502
Last Updated: 5 Mar 2007
Review Date: 4 Mar 2009








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